Acute Ankle Sprains

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Acute AnkleSprains

• Stephen Compton MD
• Department of Orthopaedics and Rehabilitation

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17 yo basketball player with an Ankle sprain 2
days ago in preseason practice
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Imaging

• In acute lateral ankle sprains, plain films are
  often unremarkable
• In chronic or recurrent sprains, pathologic
  findings may exist
• With syndesmotic injuries may have characteristic
  findings

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Treatment ?
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Treatment Options

• NSAIDS
• Acetaminophen
• Ice (RICE)
• Casting
• Bracing
• PT
• Surgery
• Others

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Evidence for Treatment
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NSAIDS

• Reduce swelling and pain after ankle injuries and
  may decrease the time it takes for the patient to
  return to usual activities.
• Evidence rating B

Slatyer MA. A randomized controlled trial of
piroxicam in the management of acute ankle sprain
in Australian Regular Army recruits. The Kapooka
Ankle Sprain Study. Am J Sports
Med199725544-53. Petrella R. Efficacy of
celecoxib, a COX-2-specific inhibitor, and
naproxen in the management of acute ankle sprain
results of a double-blind, randomized controlled
trial. Clin J Sport Med 200414225-31.
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Sx vs Conservative for Acute Inj

• GMMJ Kerkhoffs (Cochrane 2007)
• Insufficient evidence
• Conservative higher incidence of objective
  instability
• Surgery longer recovery, ankle stiffness,
  complications

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No Treatment Necessary?

• No RCTs supported
• Consensus immobilization is more effective than
  no treatment. (BMJ clinical evidence 2007
  Struijs P, Kerkhoffs G)

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Immobilization vs Functional treatment

• GMMJ Kerkhoffs (Cochrane 2002)
• Slightly favored Functional treatment
• time to return to work
• Time to return to sport (WMD 4.88 days)
• Return to work at short term follow-up (RR 5.75)
• Time to return to work (WMD 8.23 days)
• Persistent swelling at short term follow-up (RR
  1.74)
• objective instability as tested by stress X-ray
  (WMD 2.60)
• Satisfaction with their treatment (RR 1.83)
• No different between No treatment/Immob/ImmobPT
• No results were significantly in favor of
  immobilization

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Acute Ankle Sprain Rx
Is immobilization or functional treatment
indicated for acute ankle sprains?

• 9 RCTs of mobilization vs cast Rx
• Number of trials excluded for bias
• Both methods had significant variability

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Different Functional Strategies

• GMMJ Kerkhoffs (Cochrane 2002)
• Best method is unclear
• Lace-up ankle support reduce swelling
• Semi-rigid ankle support shorter time to return
  to work sport, less symptomatic instability at
  short-term follow-up (Evidence rating B)
• Tape treatment More complications esp. skin
  irritation
• Elastic bandage More Instability, Slower return
  to work and sports

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Ankle Braces
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Ankle Taping
American Orthopaedic Foot Ankle Society
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Graded exercise regimens

• Reduce the risk of ankle sprain.
• Evidence rating B
• Proprioceptive, stretching and strengthening.

Handoll HH. Interventions for preventing ankle
ligament injuries. Cochrane Database Syst Rev
2001(3)CD000018. Verhagen E. The effect of a
proprioceptive balance board training program for
the prevention of ankle sprains a prospective
controlled trial. Am J Sports Med 2004321385-93.
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Other Modalities

• Therapeutic Ultrasound DAWM Van der Windt
  (Cochrane 2002)
• Results do not support the use of ultrasound
• Hyperbaric oxygen therapy M Bennett (Cochrane
  2005)
• Insufficient evidence
• Cryotherapy Wilkerson GB (J Orthop Sports Phys
  Ther 1993)
• Insufficient evidence

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Recommendations
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R.I.C.E. Protocols

• "Rest" limit weight bearing, crutches if
  necessary, an ankle brace helps control swelling
  and adds stability
• "Ice" No ice directly on the skin, no ice more
  than 20 minutes at a time to avoid frost bite.
• "Compression" can be helpful in controlling
  swelling and is usually accomplished with an ACE
  bandage.
• "Elevate" above the waist or heart as needed

AOFAS updated Jan 2008
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Rehabilitation Goals

• Weight bearing
• ROM
• Strength and Propioception

AOFAS updated Jan 2008
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Stretching Exercise
Strengthening Exercise
American Orthopaedic Foot Ankle Society
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Propioceptive Exercise
American Orthopaedic Foot Ankle Society
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Prevention

• Handoll HHC (Cochrane 2001)
• Semi-rigid orthoses or air-cast braces can
  prevent ankle sprains during high-risk sporting
  activities (e.g. soccer, basketball) (RR 0.53,
  95 CI 0.40 to 0.69)
• Participants with a history of previous sprain
  can be advised that wearing such supports may
  reduce the risk of incurring a future sprain.
• any potential prophylactic effect should be
  balanced against the baseline risk of the
  activity, the supply and cost of the particular
  device, and for some, the possible or perceived
  loss of performance.
• Evidence rating B

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When to go see a doctor?

• Unable to bear weight
• Significant swelling
• Significant deformity
• Getting worse or no improvement in 2-3 days

AOFAS updated Jan 2008
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What is the role of physicians?
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Making the Diagnosis

• Good physical examination
• R/o Fracture Ottawas rules
• R/o other associated injuries
• Evaluate the degree of instability
• Proper investigation

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Ottawa Ankle Rules

• X-rays are only required if there is any pain in
  the malleolar area, and any one of the following
• Bone tenderness along the distal 6 cm of the
  posterior edge of the tibia or tip of the medial
  malleolus
• Bone tenderness along the distal 6 cm of the
  posterior edge of the fibula or tip of the
  lateral malleolus
• An inability to bear weight both immediately and
  in the emergency department for four steps.

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AAOS recommendations

• Gr I RICE
• Gr II RICE /- Splinting
• Gr III SLC or walking boot for 2-3 weeks

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17 yo male basketball player twisted his ankle
in practice
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The high ankle sprain or syndesmosis injury

• 1-10 of all ankle sprains
• External rotation or abduction force at ankle
• Severe inversion force rarely a cause

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Physical Examination

• Point tenderness/swelling over the AITFL and IM
• Squeeze Test

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Physical Examination

• External rotation stress test
• Stability test (2 cloth tape above malleoli)
• Pain relief with weight bearing/jumping confirms
  diagnosis

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Syndesmosis Sprains
Is there a best evidence method for syndesmosis
sprain treatment?

• NO level I studies
• 6 level IV studies ( case series )
• Athletes ( college and pro )
• Prospective or consecutive series

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Syndesmosis Sprains
Conclusions ( level IV )

• Spectrum of injury ( time loss 2-137 days )
• Poor diagnostic/prognostic criteria
• Most injuries get better long term
• Effect of early intervention ?

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Summary

• Most ankle sprains can be successfully treated
  with a standardized proprioceptive-based
  rehabilitation program
• Mechanical and functional instability must both
  be corrected
• Indication for Sx failed nonoperative treatment
  in patients with mechanical ankle instability

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Thank you for your attention.